Chapter 43 - Surgery for Vertigo

Question 1

Meniere’s Triad

Answer 1

Vertigo lasting 20+ minutes, more than 1 episode
Hearing loss
Tinnitus or aural fullness

Question 2

Surgical options for Meniere’s

Answer 2

intratympanic steroid
endolymphatic sac surgery
intratympanic gentamicin ablation
surgical labrinthectomy
vestibular nerve section

Question 3

Do any surgeries for Meniere’s improve hearing?

Answer 3

No

Question 4

Procedures for intractable or recurrent BPPV

Answer 4

posterior SCC occlusion- prevents particles from activating the canal ampulla
vestibular neurectomy (rare)
singular neurectomy- remove innervation to posterior canal ampulla (technically difficult, risk of hearing loss)

Question 5

How do you balance after a labryinthectomy?

Answer 5

Vestibular compensation - CNS process

Expedited by PT

Question 6

Can BPPV follow vestibular neuritis?

Answer 6

Yes, it often does

PT in addition to canalith repositioning can especially help in this setting

Question 7

Presentations of S SCC dehiscence

Answer 7

CHL, ear fullness/autophony (like patulous ET), vertigo

Question 8

Key finding telling you that CHL is from S SCC dehisence not otosclerosis

Answer 8

intact ipsilateral stapedial reflex

Question 9

Non-surgical treatments for vertigo

Answer 9

Based on cause...
vestibular rehab
diuretic/migraine med/vestibular suppressant
dietary change
canalith reposition

Question 10

When to consider surgery for vertigo

Answer 10

caused by unilateral peripheral vestibular dysfunction, absolute certainly of which side is affected
PLUS: disabling
PLUS: no evidence of central system dysfunction that would impair postop compensation

Question 11

Reporting Meniere’s control after treatment

Answer 11

18-24 mo after treatment, divide # episodes in 6 mo by # of episodes in 6 mo prior to treatment

A: 0%
B: 1-40% (substantial control)
C: 41-80% (partial control)
D: 81-120% (No control)
E: >120% (worse)
F: Secondary treatment required due to disabling vertigo

Question 12

Ablative vs non-ablative procedures for Meniere’s disease

Answer 12

Ablative achieves better vertigo control, but requires vestibular compensation to limit post-treatment disequilibrium

Question 13

Types of endolymphatic shunt surgery

Answer 13

Shunt: place synthetic shunt to drain endolymph
Drainage: incision of sac to allow endolymph drainage
Decompression: improve sac function of endolymph absorption

Question 14

Sham Surgery Trial Thompson 1981

Answer 14

Compared mastoidectomy w/o decompression to endolymphatic shunt
Found that benefits of shunt surgery were nonspecific, basically sham resulted in similar results as shunt surgery

Question 15

Approaches to vestibular nerve section

Answer 15

Middle fossa
Retrolabyrinthine
Restrosigmoid
Translayrinthine

Question 16

Potential complications of vestibular nerve section

Answer 16

facial paralysis, hearing loss, CSF leak, persistent disequilibrium

Question 17

Tullio’s phenomenon

Answer 17

Sound-induced dizziness, vertigo, nystagmus

Occurs with fenestration of bony labyrinth, syphilis, lyme disease

Question 18

What is S SC dehiscence

Answer 18

thinning of absence of T bone overlying S SCC

Question 19

Symptoms of S SC dehiscence

Answer 19

sound, pressure or vibration-induced vertigo
low frequency CHL, may have better than 0dB BC threshold
Autophony and blocked ear feeling

Question 20

Tests to confirm S SC dehisence

Answer 20

VEMP- low thresholds

High Res CT dehiscence of bony covering separating dura from SCC

Question 21

Cause of S SC dehiscence

Answer 21

multifactorial
incomplete ossification
chronic INC ICP
temporal-mastoid encephalocele associated

Question 22

Treatment options for SSCD

Answer 22

educate
PE tubes for pressure-induced vertigo
ear plugs for autophony
surgery to plug (w/ cartilage) or resurface SC if fail/intractable

Question 23

Approaches for SSC surgery

Answer 23

Middle cranial fossa (#1)

Transmastoid